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ABOUT COMMUNITY HEALTH CENTERS
*Includes patients of federally-funded health centers, non-federally funded health centers (health center “look-alikes”), and expected patient growth for 2016.
Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
The National Association of Community Health Centers (NACHC) is pleased to present Community Health Center Chartbook, an overview of the Health Center Program and the communities they serve. Health centers began over fifty years ago as part of President Lyndon B. Johnson’s declared “War on Poverty.” Their aim then, as it is now, is to provide affordable, high quality, comprehensive primary care to medically underserved populations, regardless of their insurance status or ability to pay for services. A growing number of health centers also provide dental, behavioral health, pharmacy, and other important services. No two health centers are alike, but they all share one common purpose: to provide primary and preventive health care services that are coordinated, culturally and linguistically competent, and community-directed.
Health centers play a critical role in the U.S. health care system, delivering care to over 25 million* people today. Across the country, health centers produce positive results for their patients and for the communities they serve. They stand as evidence that communities can improve health, reduce health disparities, and deal with a multitude of costly and significant public health and social problems – including substance abuse, HIV/AIDS, mental illness, and homelessness – if they have the resources to do so. Federal and state support, along with adequate third party reimbursement, are critically important to keep pace with escalating health care needs and rising costs among populations served by health centers.
Who health centers serve, what they do, and their impressive record of accomplishment in keeping communities healthy are represented in the following charts.
ABOUT THIS CHARTBOOK
This Chartbook highlights data from and research findings on Community, Migrant, Homeless and Public Housing Health Centers, as well as other
Federally-Qualified Health Centers (FQHCs). In this document, unless otherwise noted, the term “health center” is generally used to refer to organizations that receive grants under the Health Center Program as authorized under section 330 of the Public Health Service Act, as amended (referred to as “grantees”). Data and research sources can be found at the bottom of each figure. Most
slides draw from the Uniform Data System (UDS) maintained by the Bureau of Primary Health Care, HRSA, DHHS. UDS data included in this Chartbook are
limited to health centers that meet the federal grant requirements and receive federal funding from the Bureau of Primary Health Care. For more information
about UDS data, visit https://bphc.hrsa.gov/uds/datacenter.aspx.
About Community Health Centers About this Chartbook
Section I: Who Health Centers Serve Figure 1.1: Health Centers ServeFigure 1.2: Health Center Patients Are Predominately Low Income Figure 1.3: Most Health Center Patients are Members of Racial and Ethnic Minority Groups Figure 1.4: Health Center Patients are Disproportionately Members of Racial/Ethnic Minority GroupsFigure 1.5: Health Centers Serve Patients Throughout the Life CycleFigure 1.6: Most Health Center Patients are Publicly Insured or UninsuredFigure 1.7: Health Center Patient Mix is Unique Among Ambulatory Care ProvidersFigure 1.8: Health Center Patients are Disproportionately Poor, Uninsured, and Publicly-InsuredFigure 1.9: Many Health Center Patients Suffer from Chronic ConditionsFigure 1.10: Health Centers Serve Many Special PopulationsFigure 1.11: Health Centers Serve Disproportionate Amounts of Special PopulationsFigure 1.12: Health Centers Insurance Revenue Sources Do Not Resemble Those of Private Physicians
Section II: Expanding Access to CareFigure 2.1: Health Center Grantee Organizations and Sites, 2006-2015 Figure 2.2: The Number of Health Center Patients and Visits Continues to Increase Figure 2.3: Health Center Patients by Insurance Status, 2006-2015Figure 2.4: Even as More Patients Receive Insurance, Health Centers are Serving Increasingly More of the Nation’s UninsuredFigure 2.5: The Number of Health Center Patients in Poverty is Growing Faster than the Number in Poverty Nationally, 2006-2015Figure 2.6: The Number of Health Center Medicaid Patients Grew Faster than the Number of Medicaid Beneficiaries Nationally, 2006-2015 Figure 2.7: Health Centers Have Expanded the Breadth of Services Offered to Both New and Existing PatientsFigure 2.8: Health Centers Have Expanded Their Capacity to Provide More Services by Employing a Wider Variety of Staff Types and Integrating CareFigure 2.9: Health Centers Have Higher Rates of Accepting New Patients Regardless of Insurance Coverage Compared to Other Primary Care Providers
Table of Contents
Figure 2.10: Percent of Uninsured Served by Health Centers, 2014Figure 2.11: Percent of Medicaid Beneficiaries Served by Health Centers, 2014Figure 2.12: Federal Health Center Appropriation History, FY2004-2016 Health Centers Provide a Broad Array of Services
Section III: High Quality Care and Reducing Health DisparitiesFigure 3.1: Health Centers Perform Better on Ambulatory Care Quality Measures than Private Practice PhysiciansFigure 3.2: Health Centers Exceed Medicaid Managed Care Organization High Performance Benchmark ScoresFigure 3.3: Health Center Patients Have Higher Rates of Blood Pressure and Diabetes Control than the National AverageFigure 3.4: Health Center Patients Have Lower Rates of Low Birth Weight than the U.S. AverageFigure 3.5: Health Centers Provide More Preventive Services than Other Primary Care ProvidersFigure 3.6: Many Health Centers Exceed Healthy People 2020 Goals by Key Health OutcomesFigure 3.7: Health Center Patients Are More Satisfied with the Overall Care Received Compared with Low Income Patients NationallyFigure 3.8: Health Center Women Needing Mammograms are More Likely to Receive Them than Their Counterparts NationallyFigure 3.9: Health Center Women Needing Pap Smears are More Likely to Receive Them than Their Counterparts NationallyFigure 3.10: Health Center Patients Needing Colorectal Cancer Screenings Are More Likely to Receive Them than Their Counterparts NationallyFigure 3.11: Health Center Patients Have Lower Rates of Low Birth Weight than Their U.S. Counterparts Figure 3.12: Health Centers Reduce Disparities in Medicaid Patients’ Receipt of New Medications for Uncontrolled Hypertension Compared to Privately Insured Patients
Section IV: Cost-Effective CareFigure 4.1: Health Centers’ Average Daily Cost Per Patient is Lower Compared to All Physician SettingsFigure 4.2: Health Centers Save 24% Per Medicaid Patient Compared to Other ProvidersFigure 4.3: Health Centers Have Lower Total Spending Per Medicaid Patient Compared to Other ProvidersFigure 4.4: Health Centers Save 35% Per Child, Compared to Other ProvidersFigure 4.5: Areas with High Health Center Penetration Spend $926 Less per Medicare Beneficiary than Areas with Low Health Center PenetrationFigure 4.6: Health Centers are Associated with Lower Total Costs of Care for Medicare Patients Compared to Other ProvidersFigure 4.7: Health Centers Save $1,263 Per Patient Per Year
Section V: Health Center Services and Staffing Figure 5.1: Health Center Care Team Staff Provide a Broad Array of ServicesFigure 5.2: Health Centers Medical Services Staff, 2015Figure 5.3: Health Centers Dental Services Staff, 2015 Figure 5.4: Health Centers Behavioral Health Services Staff, 2015 Figure 5.5: Health Centers Enabling Services Staff, 2015 Figure 5.6: Growth in Health Center Medical Providers, 2006-2015Figure 5.7: Health Centers are Hiring Non-Physician Providers at Higher Rates than Physicians
Section VI: Challenges in Meeting Demand for Care Figure 6.1: Health Center Funding Per Uninsured Patient is Well Below Total Per Patient CostFigure 6.2: Payments From Third Party Payers are Less Than Cost, 2015Figure 6.3: Health Center Operating Margins are Less Than Hospital Operating Margins Figure 6.4: 26 States Will Provide Funding to Health Centers in State Fiscal Year 2017 Figure 6.5: Estimated Percent of County Residents Experiencing Shortages of Primary Care Physicians, 2013Figure 6.6: Health Center Capital Project Plans and Funding Needs
Section I Who Health Centers Serve
Figure 1.1
Note: Includes patients of federally-funded health centers and non-federally funded health centers, and expected patient growth for 2016. Sources: NACHC, 2017. Analysis based on 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. US Census Bureau. Health Insurance Coverage in the United States: 2015. September 2016. Kaiser Family Foundation. Total Monthly Medicaid and CHIP Enrollment: December2015. US Census Bureau. Income and Poverty in the United States: 2015. September 2016. Kaiser Family Foundation. Population Distribution by Metropolitan Status: 2015.
Note: Federal Poverty Level (FPL) for a family of three in 2015 was $20,090. (See https://aspe.hhs.gov/2015-poverty-guidelines). Based on percent known. Percents may not total 100% due to rounding. Source: Federally-funded health centers only. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
Figure 1.2
Health Center Patients are Predominately Low Income
100% FPL and Below71%
101-150% FPL15%
151-200% FPL7%
Over 200% FPL8%
Note: Based on percent known. Percents may not total 100% due to rounding. The 62% of health center patients that are members of racial and ethnic minorities is not shown in this figure.Source: Federally-funded health centers only. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
Figure 1.3
Most Health Center Patients are Members of Racial and Ethnic Minority Groups
62% of health center patients are members of racial and ethnic minority groups
Asian/Hawaiian/Pacific Islander5%
Black/African American
23%
American Indian/Alaska
Native1%White
67%
More than one race4%
Hispanic/Latino35%
Non-Hispanic/Latino65%
Figure 1.4
Health Center Patients are Disproportionately Members of Racial/Ethnic Minority Groups
Sources: Based on 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. U.S. Census Bureau, Population Division: “Annual Estimates of the Resident Population by Sex, Race, and Hispanic Origin for the United States, States, and Counties: April 1, 2010 to July 1, 2015” Released June 2015.
35%
23%
5%1%
18%
13%
6%
1%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Hispanic/Latino African American/Black Asian/Hawaiian/PacificIslander
American Indian/AlaskaNative
Health Centers United States
Figure 1.5
Health Centers Serve Patients Throughout the Life Cycle
Source: Federally-funded health centers only. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Note: Percents may not total 100% due to rounding.
Under 510%
Ages 5-1214%
Ages 13-1910%
Ages 20-247%
Ages 25-4427%
Ages 45-6424%
Ages 65+8%
Notes: Percents may not total 100% due to rounding. ”Other public insurance” may include non-Medicaid CHIP and state-funded insurance programs.Source: Federally-funded health centers only. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
Figure 1.6
Most Health Center Patients are Publicly Insured or Uninsured
Uninsured24%
Medicaid49%
Medicare9%
Other Public Insurance1%
Private17%
Note: Private Physician and Emergency Department numbers may not add up to 100% because of rounding and more than one category could be indicated.Sources: 2015 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. National Center for Health Statistics. National Ambulatory Medical Care Survey, 2013. Table 7. Expected Sources of Payment at Office Visits: United States, 2013. National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey, 2013. Table 6. Expected Sources of Payment at Emergency Department Visits: United States, 2013.
Figure 1.7
Health Center Patient Mix is Unique Among Ambulatory Care Providers
49%
13%
30%
9%
27%
20%
24%
4%
15%
17%
60%
36%
1%10% 11%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Health Center Private Physician Emergency Department
Other/Unknown
Private
Uninsured
Medicare
Medicaid
Figure 1.8
Health Center Patients are Disproportionately Poor, Uninsured, and Publicly-Insured
Poverty levels based on percent known.Sources: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Kaiser Family Foundation, State Health Facts Online, www.statehealthfacts.org. US Census Bureau. March 2015 Current Population Survey (CPS: Annual Social and Economic Supplements).
24%
49%
71%
92%
9%
20%14%
32%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Uninsured Medicaid At or below 100% ofPoverty
Under 200% of Poverty
Health Centers United States
Figure 1.9
Many Health Center Patients Suffer From Chronic Conditions
* Other than during pregnancy. Source: 2014 Health Center Patient Survey. Bureau of Primary Health Care, HRSA, DHHS.
42%
33%
22%
15%
32%
22%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
High cholesterol Hypertension Asthma Diabetes* Health is fair orpoor
Needed mentalhealth care in the
past year
Percent of patients who report ever being told they have: Percent of patients reporting:
Figure 1.10
Health Centers Serve Many Special Populations
910,172Agricultural
Worker Patients
649,132School-Based Health
Center Patients
1,191,772Homeless Patients
1,510,842Public Housing
Patients
305,520Veteran Patients
Source: 2015 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.
3%
5%
6%
0.95%
0.18%0.68%
Migratory/Seasonal Farmworkers Homeless Persons Residents of Public Housing
Figure 1.11
Health Centers Serve Disproportionate Amounts of Special Populations
Percent of HC Population Percent of US Population
Sources: 2015 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. National Center for Farmworker Health, Inc. Farmworker Factsheet. August 2012. National Alliance to End Homelessness. The State of Homelessness in America, 2015. Center on Budget and Policy Priorities. Policy Basics: Public Housing. May 31, 2016. US Census Bureau. March 2015 Current Population Survey (CPS: Annual Social and Economic Supplements).
Figure 1.12
Health Centers’ Insurance Revenue Sources Do Not Resemble Those of Private Physicians
Note: Health Centers includes third party revenue only. Private Physicians does not equal 100% because more than one category could be indicated. Numbers also may not add to 100% because of rounding.Sources: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. National Center for Health Statistics. National Ambulatory Medical Care Survey, 2013. Table 7. Expected Sources of Payment at Office Visits: United States, 2013.
68%
13%
10%
27%
2%
13%
60%
7%4%
0%
20%
40%
60%
80%
100%
Health Center Private Physicians
Self-Pay/Uninsured
Private Insurance
Other Public Insurance
Medicare
Medicaid/SCHIP
Section IIExpanding Access to Care
Figure 2.1
Health Center Grantee Organizations and Sites, 2006-2015
Source: Federally-funded health centers only. 2006-2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
1,002 1,067 1,080
1,131 1,124 1,128 1,198 1,202
1,278
1,375
6,139
6,612 8,320
7,257 6,949
7,621
8,912 9,170 8,801 9,754
-
2,000
4,000
6,000
8,000
10,000
12,000
-
200
400
600
800
1,000
1,200
1,400
1,600
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Nu
mb
er
of
Site
s
Nu
mb
er
of
Gra
nte
e O
rgan
izat
ion
s
Figure 2.2
The Number of Health Center Patients and Visits Continues to Increase
Source: Federally-funded health centers only. 2006-2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
62% growth in patients and 64% growth in visits
since 2006
15.016.1
17.118.8 19.5 20.2
21.1 21.722.9
24.3
59.263.0
66.9
73.877.1
80.0 83.8 85.690.4
97.0
0
20
40
60
80
100
120
0
5
10
15
20
25
30
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Total P
atient V
isits (in m
illion
s)To
tal P
atie
nts
(in
mill
ion
s)
Figure 2.3
Health Center Patients by Insurance Status, 2006-2015
Source: Federally-funded health centers only. 2006-2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
Medicaid
Uninsured
Private
Medicare
Other Public Insurance
6.0 6.26.6
7.2
7.3 7.4 7.6 7.6
6.45.9
5.35.7 6.1
6.9
7.58.0
8.48.8
10.711.9
2.3 2.5 2.7 2.7 2.7 2.9 3.0 3.13.6
4.1
1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 2.0 2.2
0.40.4 0.5 0.5
0.5 0.5 0.5 0.4 0.3 0.2
0
1
2
3
4
5
6
7
8
9
10
11
12
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Nu
mb
er o
f P
atie
nts
(in
mill
ion
s)
Note: Proportion of all US residents does not account for health centers located in U.S. territories. Sources: 2012 and 2015 Uniform Data System. Bureau of Primary Health Care. HRSA, DHHS. U.S. Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2012. Current Population Reports, P60-245. and Health Insurance Coverage in the United States: 2015. Current Population Reports, P60-257.
Figure 2.4
Even as More Patients Receive Insurance, Health Centers are Serving Increasingly More of the
Nation’s Uninsured
Figure 2.5
The Number of Health Center Patients in Poverty is Growing Faster than the Number in Poverty Nationally,
2006 - 201554%
18%
0%
10%
20%
30%
40%
50%
60%
Health Center Low Income Low Income Nationally
Per
cen
t G
row
th
Note: Represents patients/people under 100% of the federal poverty level. Source: 2006-2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. US Census Bureau, Historical Poverty Data, Table 2: Poverty Status of People By Family Relationship, Race, and Hispanic Origin.
Figure 2.6
The Number of Health Center Medicaid Patients is Growing Faster than the Number of Medicaid
Beneficiaries Nationally, 2006-2015
125%
72%
0%
20%
40%
60%
80%
100%
120%
140%
Health Center Medicaid Medicaid Nationally
Per
cen
t G
row
th
Sources: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Kaiser Family Foundation. Medicaid Enrollment Snapshot: December 2013. Table A-2: Total Medicaid Enrollment by State, December 2006 – 2013.
Figure 2.7
Health Centers Have Expanded the Breadth of Services Offered to Both New and Existing Patients
Note: Behavioral health refers to mental health and substance abuse. Sources: 2015 and 2010 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
Figure 2.8
Health Centers Have Expanded Their Capacity to Provide More Services by Employing a Wider Variety of Staff Types and
Integrating Care
Note: Behavioral health refers to mental health and substance abuse. Sources: 2015 and 2010 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
Source: Hing E, Hooker RS, Ashman JJ. Primary Health Care in Community Health Centers and Comparison with Office-Based Practice. J Community Health. 2011 June; 36(3): 406-13.
Figure 2.9
Health Centers Have Higher Rates of Accepting New Patients Compared to Other Primary Care Providers
98% 97% 96%
81%
93%
66%
76%
39%
0%
20%
40%
60%
80%
100%
120%
New Patients New Medicaid Patients New Medicare Patients New Uninsured
Health Center Other Primary Care Providers
Figure 2.10
Percent of Uninsured Served by Health Centers, 2015
Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Kaiser Family Foundation. Distribution of the Nonelderly Uninsured. U.S. Census American Fact Finder. Health Insurance Coverage Status, 2015 American Community Survey 1-year Estimates, Puerto Rico.
CT – 26%DC – 44%DE – 20%MA – 41%MD – 14%NH – 18%NJ – 18%RI – 37%VT – 32%
% of Uninsured Served by Health
Centers
< 15.2%
15.2 – 21.8%
21.8 – 27.6%
27.6 – 36.8%
>36.8%
30% 12%
30%
27%
18%39%
10% 15%
25%31%
16%
23%
15%
31%
25%
8%
17%
32%
31%
21%28%
18%
51%
26%
25%
23%
40%
18%
14%
12%
18%
24%
30%
12%
12%
20%
25%
18%
36%
25%12%
13%
22%
Figure 2.11
Percent of Medicaid Beneficiaries Served By Health Centers, 2015
11%
21%
14%
21%
8%
24%
16%
CT – 30%DC – 35%DE – 8%MA – 21%MD – 13%NH – 15%NJ – 17%RI – 31%VT – 26%
6%
14%
14%
25%
16%24%
16%14%
14%
15%
16%
8%
11%
24%
6%
10%
12%
17%
16%
6% 12%
21%
8%14%
13%
13%
7%
8%
8%
8%27%
18%
32%
5%
% Medicaid Patients Served by Health
Centers
< 8.04%
8.04 – 13.34%
13.34 – 15.84%
15.84 – 22.26%
>22.62%Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Monthly Medicaid and CHIP Enrollment, December 2015, Kaiser Commission on Medicaid and the Uninsured. Medicaid.gov. Puerto Rico. Monthly Medicaid and CHIP Enrollment Data.
14%
Figure 2.12
Federal Health Center Appropriation History, FY2004-FY2016
Note: Federal appropriations are for consolidated health centers under PHSA Section 330. Federally funded health centers only .
$1.78 $1.99 $2.07 $2.19 $2.19
$2.60 $2.78
$2.99
$3.69
$5.1 $5.1 $5.1
$-
$1.0
$2.0
$3.0
$4.0
$5.0
$6.0
FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17
Ap
pro
pri
atio
ns
(in
bill
ion
s)
Section IIIHigh Quality Care and Reducing
Health Disparities
Sources: Goldman, LE et al. Federally Qualified Health Centers and Private Practice Performance on Ambulatory Care Measures. American Journal of Preventive Medicine. 2012. 43(2):142-149. *Fontil et al. Management of Hypertension in Primary Care Safety-Net Clinics in the United States: A Comparison of Community Health Centers and Private Physicians’ Offices. Health Services Research. April 2017. 52:2.
Figure 3.1
Health Centers Perform Better on Ambulatory Care Quality Measures than Private Practice Physicians
16%
37%
44%
47%
86%
84%
93%
18%
51%
57%
59%
90%
91%
99%
0% 20% 40% 60% 80% 100% 120%
Prescription of new antihypertensive medicationfor uncontrolled hypertension*
Ace inhibitor use in congestive heart failure
Aspirin use in coronary artery disease
β-Blocker use in coronary artery disease
Blood pressure screening
No use of benzodiazepines in depression
No electroardiogram screening in low-riskpatients
Health Centers
Private PracticePhysicians
Percentage of Patients
79%73%
81%
71%
63%
54%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Diabetes Control Blood Pressure Control Pap Test
Sha
re o
f P
atie
nts
Me
etin
g Q
ua
lity
Be
nch
mar
k
Average Rate in High-Performing Health Centers Average Rate in All Health Centers
Figure 3.2
Health Centers Exceed Medicaid Managed Care Organization High Performance Benchmark Scores
Note: Quality Measures include control of diabetes: share of patients with diabetes with HbA1c between 7% and 9%; Control of hypertension: share of patients with hypertension with blood pressure < 140/90 mm Hg; Pap Tests: share of female patients age 24 – 64 who received Pap test within past three years.Source: Shin P, Sharac J, Rosenbaum S, Paradise J. Quality of care in community health centers and factors associated with performance. Kaiser Commission on Medicaid and the Uninsured Report #8447 (June 2013).
Medicaid MCO High Performance Benchmark (75th percentile)
62% 62%
72%
Figure 3.3
Health Center Patients Have Higher Rates of Diabetes and Blood Pressure Control than the National Average
* Estimated percentage of patients with Hba1c < 9% † Estimated percentage of patients with blood pressure < 140/90Sources: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. National Center for Health Statistics. NCHS Data Brief. No. 220. November 2015. Hypertension Prevalence and Control Among Adults: United States, 2011 – 2014. National Committee for Quality Assurance. Comprehensive Diabetes Care, The State of Health Care Quality (2016).
70%
64%
54% 52%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Diabetes Blood Pressure
Health Centers
National
* †
Figure 3.4
Health Center Patients Have Fewer Low Birth Weight Babies than the US Average
Sources: 2010-2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. National Center for Health Statistics (NCHS).
8.1%
7.9%8.0% 8.0% 8.0%
8.1%
7.4% 7.4%
7.1%
7.3% 7.3%
7.6%
6.6%
6.8%
7.0%
7.2%
7.4%
7.6%
7.8%
8.0%
8.2%
2010 2011 2012 2013 2014 2015
United States Health Centers
Source: Shi L, Tsai J, Higgins PC, Lebrun La. (2009). Racial/ethnic and socioeconomic disparities in access to care and quality of care for US health center patients compared with non-health center patients. J Ambul Care Manage 32(4): 342 – 50. Shi L, Leburn L, Tsai J and Zhu J. (2010). Characteristics of Ambulatory Care Patients and Services: A Comparison of Community Health Centers and Physicians' Offices J Health Care for Poor and Underserved 21 (4): 1169-83. Hing E, Hooker RS, Ashman JJ. (2010). Primary Health Care in Community Health Centers and Comparison with Office-Based Practice. J Community Health. 2011 Jun; 36(3): 406 – 13.
Figure 3.5
Health Centers Provide More Preventive Services than Other Primary Care Providers
15%
19%
81%
65%
37%
24%
33%
85%
70%
51%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Asthma Education for Asthmatic Patients
Tobacco Cessation Education for Smoking Patients
Pap Smears in the last 3 years
Immunizations for 65 years and older
Health Education
Health Center Patients Visits Patient Visits to Other Providers
Figure 3.6
Many Health Centers Exceed Healthy People 2020 Goals by Key Health Outcomes
15%
37%
60%
93%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hypertension Control Diabetes Control Low Birth Weight Meet or Exceed at LeastOne Goal
% Meeting or Exceeding Healthy People 2020 Goal
Sources: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Office of Disease Prevention and Health Promotion. Healthy People 2020. 2020 Topics and Objectives.
Figure 3.7
Health Center Patients Are More Satisfied with the Overall Care Received Compared with Low Income Patients Nationally
Shi L, Lebrun-Harris LA, Daly CA, et al. Reducing Disparities in Access to Primary Care and Patient Satisfaction with Care: The Role of Health Centers. Journal of Health Care for the Poor and Underserved. 2013; 24(1):56-66.
96% 98%
37%
87%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Satisfied with Hours of Operation Satisfied with Overall Care Received
Health Center Patients Low Income Patients Nationally
Figure 3.8
Health Center Women Needing Mammograms are More Likely to Receive Them than Their Counterparts
Nationally
*Includes women below 100% FPL or at 100% FPL and belowSource: Health Resources and Services Administration, 2014 Health Center Patient Survey. Female Health Center Patients Aged 40+ Who Had a Mammogram in the Past 2 Years. US Census Bureau. Health, United States, 2015. Table 70. Use of Mammography Among Women Aged 40 and Over, by Selected Characteristics: United States, Selected Years 1987 – 2013.
76%82%
69%63%61%
67%
50%
37%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Hispanic Black In Poverty* Uninsured
Health Centers Nationally
Figure 3.9
Health Center Women Needing Pap Smears are More Likely to Receive Them than Their Counterparts
Nationally92% 89%
82%76%
71%75%
61% 58%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hispanic Black In Poverty* Uninsured
Health Centers Nationally*Includes women below 100% FPL or at 100% FPL and belowSource: Health Resources and Services Administration, 2014 Health Center Patient Survey. Female Health Center Patients Aged 18+ Who Had a Pap Smear in the Past 3 Years. US Census Bureau. Health, United States, 2015. Table 71. Use of Pap Smears Among Women Aged 18 and Over, by Selected Characteristics: United States, Selected Years 1987 – 2013.
Figure 3.10
Health Center Patients Needing Colorectal Cancer Screenings Are More Likely to Receive Them than Their
Counterparts Nationally
55% 55% 57%
38%
54%
41%
0%
10%
20%
30%
40%
50%
60%
Hispanic Black In Poverty*
Health Centers Nationally
*Includes individuals below 100% FPL or at 100% FPL and belowSource: Health Resources and Services Administration, 2014 Health Center Patient Survey. Health Center Patients Aged 50+ Who Ever Had a Colonoscopy. US Census Bureau. Health, United States, 2015. Table 72. Use of Colorectal Tests or Procedures Among Adults Aged 50-75, by Selected Characteristics: United States, Selected Years 2000 – 2013.
Figure 3.11
Health Center Patients Have Lower Rates of Low Birth Weight than Their U.S. Counterparts
Source: Shi, L., et al. “America’s health centers: Reducing racial and ethnic disparities in prenatal care and birth outcomes.” 2004. Health Services Research, 39(6), Part I, 1881-1901.
7.7% 7.5%
13.0%
6.5% 6.8%
8.2%7.5%
14.9%
6.0%
9.1%
7.5%6.6%
10.7%
5.6%
7.4%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
Total Asian Black Hispanic White
US US Low Income Health Center
If the black-white low birth weight disparity seen at health centers could be achieved
nationally, there would be 17,100 fewer black low birth weight infants annually.
Figure 3.12
Health Centers Reduce Disparities in Medicaid Patients’ Receipt of New Medications for Uncontrolled Hypertension Compared to Privately
Insured Patients
Source: Fontil et al. Management of Hypertension in Primary Care Safety-Net Clinics in the United States: A Comparison of Community Health Centers and Private Physicians’ Offices. Health Services Research. April 2017. 52:2.
21%
9%
0%
5%
10%
15%
20%
25%
Health Centers
Private Practice Physicians
% of Medicaid Patients Receiving New Medication for Uncontrolled Hypertension
Section IVCost Effective Care
$3.06
$2.09
$0.00
$0.50
$1.00
$1.50
$2.00
$2.50
$3.00
$3.50
All Physician Settings Health Centers
Ave
rage
Dai
ly C
ost
Per
Pat
ien
tFigure 4.1
Health Centers’ Average Daily Cost Per Patient is Lower Compared to All Physician Settings
Source: 2014 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS., Agency for Healthcare Research and Quality. Medical Expenditure Survey. Table 8.1a: Office-based Medical Provider Services-Mean and Median Expenses per Person with Expense and Distribution of Expenses by Source of Payment: United States, 2014. Visits to physicians only.
Figure 4.2
Health Centers Save 24% Per Medicaid Patient Compared to Other Providers
$1,430 $1,964
$2,324
$216
$1,496
$7,518
$1,845
$2,948 $2,704
$244
$2,047
$9,889
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
Primary Care Other OutpatientCare
Rx Drug Spending Emergency Room Inpatient Care Total Spending
Health Centers Non-Health Centers
23% lower spending
33% lower spending
14% lower spending
11% lower spending
27% lower spending
24% lower spending
Note: Non-health centers include private physician offices and outpatient clinics.Source: Nocon et al. Health care use and spending for Medicaid enrollees in federally qualified health centers versus other primary care settings. AJPH. November 2016. 106(11): 1981-1989.
0%
10%
20%
30%
40%
50%
60%
70%
AL CA CO CT FL IA IL MS NC TX VT WV
Fig. 4.3
Health Centers Have Lower Total Spending per Medicaid Patient Compared to Other Providers
Notes: Non-health centers include private physician offices and outpatient clinics. MT was included in the national-level analyses, but did not have a large enough sample size to be included in the adjusted state-level analysesSource: Nocon et al. Health care use and spending for Medicaid enrollees in federally qualified health centers versus other primary care settings. AJPH. November 2016. 106(11): 1981-1989.
Percent Lower Spending in State Studied
63% lower
26% lower 19%
lower
27% lower
32% lower 27%
lower 19% lower
29% lower 22%
lower 15% lower
18% lower
22% lower
$1,133
$418
$163
$1,751
$697
$320
$0
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
$1,800
$2,000
Total Ambulatory Prescription Drugs
Ave
rage
An
nu
al C
ost
pe
r C
hild Health Centers
Non-Health Centers
Figure 4.4
Health Centers Save 35% Per Child, Compared to Other Providers
Source: Bruen B, Ku L. Community health centers reduce the costs of children’s health care. Geiger Gibson/RCHN Community Health Foundation Research Collaborative. Policy Research Brief #48. June 20, 2017.
35% lower spending
40% lower spending
49% lower spending
$8,616
$9,542
$9,222
$8,100
$8,400
$8,700
$9,000
$9,300
$9,600
$9,900
High Health Center Penetration Area Low Health Center Penetration Area All Areas
Notes: High health center penetration corresponds to 54% health center penetration rate among low-income residents; Low health center penetration corresponds to 3% health center penetration rate among low-income residents; Average health center penetration rate among low-income residents was 21%.Source: Sharma R, Lebrun-Harris L, Ngo-Metzger Q. Costs and Clinical Quality Among Medicare Beneficiaries: Associations with Health Center Penetration of Low-Income Residents. Medicare & Medicaid Research Review. 2014; 4(3):E1-E17.
Figure 4.5
Areas with High Health Center Penetration Spend $926 Less per Medicare Beneficiary than Areas with Low Health Center Penetration
10% Lower Medicare Spending in Areas with High Health
Center Penetration
Tota
l Me
dic
are
Co
st p
er
Be
nef
icia
ry
$2,370
$2,667
$3,580
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
Health Centers Physician Offices Outpatient Clinics
Figure 4.6
Health Centers Are Associated with Lower Total Costs of Care for Medicare Patients Compared to Other Providers
Source: Mukamel DB, White LM, Nocon RS, et al. Comparing the cost of caring for Medicare beneficiaries in federally funded health centers to other care settings. Health Serv Res. April 2016. 51(2): 625-644.
10% lower than physician office patients and 30% lower than outpatient clinic patients
Fig. 4.7
Health Centers Save $1,263 Per Patient Per Year
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
Health Center Users Non - Health Center Users
Hospital Emergency Department
Hospital Inpatient
Ambulatory
Other Services
$4,043
$5,306
Source: NACHC analysis based on Ku et al. Using Primary Care to Bend the Curve: Estimating the Impact of a Health Center Expansion on Health Care Costs. GWU Department of Health Policy. Policy Research Brief No. 14. September 2009.
Section VHealth Center Services and
Staffing
Notes: Percents may not total 100% due to rounding. NPs/Pas/CNMs represents Nurse Practitioners/Physicians Assistants/Certified Nurse Midwives. Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
Figure 5.1
Health Center Care Team Staff Provide a Broad Array of Services
10%Physicians
9%NPs/Pas/CNMs
13%Nurses
12%Dental
7%Behavioral
Health
3%Pharmacy
20%Enabling and
Other Programs and Services
1%Other
Professional Services
21%Other Medical
Personnel
2%Laboratory
1%X-Ray
104,531.7 Total Full Time Equivalent Care Team Staff
Figure 5.2
Health Center Medical Services Staff, 2015
Family Physicians
46%
General Practitioners3%
Internists16%
Obstetrician/Gynecologists
10%
Pediatricians22%
Other Specialty Physicians
3%
Total Physicians
18%
Total NPs, PAs, CNMs
15%
Nurses23%
Other Medical
Personnel44%
Total Medical Personnel = 67,627.62 Full Time Equivalents
Total Physicians = 11,867.21 Full Time Equivalents
Note: Total Physicians excludes Psychiatrists and Optometrists. NP, PA, CNM stands for Nurse Practitioners, Physician Assistants, Certified Nurse Midwives. Other Medical Personnel includes Laboratory personnel and X-Ray personnel. Percents may not total 100% due to rounding. Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
Figure 5.3
Health Center Dental Services Staff, 2015
Dentists28%
Dental Hygienists
13%
Dental Assistants,
Aides, Techs59%
Total Dental Personnel = 14,557.84 Full Time Equivalents
Source: Federally-funded health centers only. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. Percents may not total 100% due to rounding.
Figure 5.4
Health Center Behavioral Health Services Staff, 2015Psychiatrists
7%Licensed Clinical
Psychologists8%
Licensed Clinical Social Workers
30%Other Licensed Mental Health
Providers22%
Other Mental Health Staff
23%
Substance Abuse Services
11%Total = 8,740.39
Full Time Equivalents
Note: Percents may not total 100% due to rounding. Source: Federally-funded health centers only. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
Case Managers36%
Patients/Community Education Specialists
14%
Outreach Workers15%
Transportation Staff3%
Eligibility Assistance Workers
25%
Interpretation Staff5%
Figure 5.5
Health Center Enabling Services Staff, 2015
Total = 18,859.49 Full Time Equivalents
Note: Percents may not total 100% due to rounding. Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
Other Enabling Services
3%
Figure 5.6
Growth in Health Center Medical Providers, 2006 - 2015
7,595
4,292
8,776
3,018
6,250
11,867
10,332
15,857
8,740
14,558
-
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
Physicans NPs, PAs, CNMs Nurses Behavioral Health Staff Dental Staff
2006 2015
56% Increase
141% Increase
81% Increase
190% Increase
133% Increase
Note: NP, PA, CNM stand for Nurse Practitioners, Physician Assistants, Certified Nurse Midwives, respectively. Behavioral Health Staff includes Substance Abuse staff. Sources: 2006 and 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
0.54 0.55 0.54 0.55 0.56 0.57 0.59 0.61 0.63 0.660.70 0.72
0.760.81
0.87
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Ratio of PA, NP, and CNM FTEs to Physician FTEs
Notes: PA, NP, and CNM stand for Physician Assistant, Nurse Practitioner, Certified Nurse Midwife, respectively. FTE stands for Full-Time Equivalent.Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
Figure 5.7
Health Centers are Hiring Non-Physician Providers at Higher Rates than Physicians
Section VIChallenges in Meeting Demand
for Care
Figure 6.1
Health Center Funding Per Uninsured Patient Is Well Below Total Per Patient Cost
Note: Not adjusted for inflation. Federal appropriations are for consolidated health centers under PHSA Section 330.Source: 2006-2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
$267 $270 $281 $271 $273$312
$344$374
$504
$624
$538 $562 $588 $600$630 $654
$687$721
$763$827
0
100
200
300
400
500
600
700
800
900
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Annual Health Center Funding per Uninsured Patient Annual Health Center Total Cost per Total Patient
Figure 6.2
Payments from Third Party Payers Are Less Than Cost, 2015
82%
56%60% 57%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Medicaid Medicare Other Public Insurance Private Insurance
Percent of Charges Collected From Third Party
Payers
Note: Health centers are non-profits, and thus charges are a proxy for costs. Source: 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS.
Figure 6.3
Health Center Operating Margins are Less than Hospital Operating Margins
Note: Operating margin data for Hospitals in 2015 is unavailable.Sources: 2003 – 2015 Uniform Data System. Bureau of Primary Health Care, HRSA. DHHS. American Hospital Association. Trendwatch Chartbook 2016: Trends Affecting Hospitals and Health Systems. Supplementary Data Tables. Table 4.1: Aggregate Total Hospital Margins and Operating Margins; Percentage of Hospitals with Negative Total Margins; and Aggregate Non-operating Gains as a Percentage of Total Net Revenue, 1994 – 2014.
3.3% 3.6% 3.7% 4.0% 4.3%
3.3%
4.4%
5.5% 5.5%
6.5%
5.7%6.4%
1.8%
3.4% 4.7% 3.4%
1.6%
3.02%
0.5% 0.9% 1.0%0.2%
0.8%-0.1%
-1.1%
-2.4%
-0.2%
1.6%
1.1%
2.63%
4.3%
-3.0%
-2.0%
-1.0%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Hospital
Health Centers with American Recovery and Reinvestment ACT (ARRA) Funds
Health Centers without American Recovery and Reinvestment ACT (ARRA)Funds
Thanks to ARRA funding between 2009 and 2014, health center operating margins nationally were higher, but were still below those of hospitals.
MA
AK
AL
AZ
CA
DC
DE
GA
ID
KY
LA
MD
ME
MI
MT
OR
PR
SD
TX
WA
WY
IA
VTND
NVUT
RI
PA
MN
IL
VA
OH
NH
OK
MS
NE CT
KS
NC
WI
TN
HI
MO
WV
AR SCNM
INCO
FL
NJ
NY
NoneLess than $2 million$2 million to $5 million$5 million to $10 million$10 million to $50 million$50 million to $80 millionNo data available
Figure 6.4
26 States Will Provide Funding to Health Centers in State Fiscal Year 2017
Source: NACHC 2016. 2016 Annual Primary Care Association (PCA) Assessment.
Figure 6.5
Estimated Percent of County Residents Experiencing Shortages of Primary Care Physicians, 2013
Source: Created by The Robert Graham Center (2014). US Census 2010; HRSA Data Warehouse 2014 HPSA and MUA/P shapefiles; AMA Masterfile 2013; UDS Mapper 2014. The Medically Disenfranchised and the Shortage of Primary Care: The Role of Health Centers in Improving Access to Care. NACHC. March 2014.
62 million people experience inadequate or no access to primary
care because of shortages of physicians
in their communities
Figure 6.6
Health Center Capital Project Plans and Funding Needs, 2015
Source: CapLink. Health Center Capital Project Plans and Funding Needs. 2015.
• 79% of health centers have plans to initiate capital projects within the next
several years. These plans represent 2,300 capital projects
• These planned projects are estimated to cost $4.6 billion:
• which will result in 12 million square feet of new space,
• accommodating 6,100 new providers• who will serve 5.4 million new patients annually
• However 75% of health centers report funding gaps for these planned projects
